Foreign aid should be realigned to target malaria & TB

Foreign aid to the public health sectors of developing countries often appears to be allocated backwards: The global burden of non-communicable diseases such as diabetes or heart disease is enormous – yet they receive little health aid. 

By comparison, the global burden of HIV is much smaller, yet it receives more health aid than any other single disease.

So will a wholesale reversal in health aid priorities improve global health? The answer, according to a new study by Stanford researchers, is that if the goal is to maximize the health benefits from each donor dollar, health aid is actually allocated pretty well.

Still, reallocating foreign aid to step up the fight against malaria and TB could lead to greater overall health improvements in developing nations. And it could be done without spending more money, the researchers have found.

Eran Bendavid, an assistant professor in the Department of Medicine and a core faculty member at the Center for Health Policy and Center for Primary Care and Outcomes Research, and three Stanford research assistants write in the July issue of Health Affairs that more health aid is going to disease categories with more cost-effective interventions.

"What we found, somewhat to our surprise, is that in nearly all countries, more aid was flowing to finance priorities with more cost-effective options,” Bendavid said in an interview. “That is partly because more aid was flowing to the treatment and prevention of infectious diseases such as HIV and malaria, and their management can be relatively inexpensive, even if the burden of these diseases is lower than that of non-communicable diseases.”

Bendavid, an infectious disease physician, added: “Conversely, even though the burden of non-communicable diseases is high and growing, addressing these chronic conditions such as diabetes and heart disease is, broadly, more costly than the unfinished infectious disease agenda.”

The authors also show that just because health aid is broadly allocated toward better cost-effectiveness does not mean that it cannot be better allocated.

The biggest gains would come from taking some of the foreign aid earmarked for HIV or maternal, newborn or child health, and putting it toward programs to treat malaria and tuberculosis, they write.

The Stanford research team reviewed the literature for cost-effectiveness of interventions targeting five disease categories: HIV, malaria, tuberculosis, non-communicable disease and maternal, newborn and child health.

What they found was that aid from wealthy nations to developing ones might be allocated efficiently, but that the money is not always spent in the best interest of curbing the communicable diseases that would improve the overall health of a nation.

It is crucial, therefore, to further study the consequences of realignment of donor funds.

Public health aid is critical to most developing countries. Development assistance from high-income countries to public health sectors of low- and middle-income countries amounts to nearly 40 percent of public health spending in countries with a per capita GDP of less than $2,000.

The researchers focused on 20 countries that received the greatest total amount of aid between 2008 and 2011, a period of historically unprecedented growth in health aid. Development assistance has since flattened, however, so the authors believe it’s increasingly important to consider best value when investing limited resources.

The 20 countries studied ­– from Afghanistan to Zambia – received $58 billion out of the total $103.2 billion in recorded health aid disbursements to 170 countries between 2001 and 2011.

“Over the period of 2001-2011, a greater amount of disbursements flowed to HIV programs than any other disease category,” the authors write. “On average, interventions addressing malaria and had the lowest incremental cost-effectiveness ratio (ICER), which indicates that malaria interventions could yield greater health improvements from each dollar compared with the interventions having a higher ICER.”

The authors analyzed the data and determined that the alignment improves if up to 61 percent of HIV aid is reallocated for TB control and up to 80 percent is reallocated for malaria control.

“Our evidence suggests that the greatest improvements in the efficiency of global health dollars could result from reallocating funds to malaria and TB control programs,” the authors write.

“This study shows, for the first time, that the current allocation of health aid is generally aligned with the cost-effectiveness of targeted interventions. Contrary to common views that advocate for reprioritization toward non-communicable diseases, our data suggest that the alignment could best be improved by focusing on malaria and TB, especially where addressing those diseases is highly cost effective.”

The other authors of the study are Andrew Duong and Gillian Raikes, both research assistants in the Program of Human Biology; and Charlotte Sagan, a RA in the School of Medicine.